Healthcare Provider Details

I. General information

NPI: 1629082391
Provider Name (Legal Business Name): PETER KEN KANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1952A PULASKI HWY
EDGEWOOD MD
21040-1617
US

IV. Provider business mailing address

3 NASHUA CT SUITE H
BALTIMORE MD
21221-3133
US

V. Phone/Fax

Practice location:
  • Phone: 410-538-7000
  • Fax: 410-679-7825
Mailing address:
  • Phone: 410-933-5678
  • Fax: 410-933-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberD0012744
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: